Provider Demographics
NPI:1740649649
Name:MAROON, ILEANA P (DDS)
Entity type:Individual
Prefix:DR
First Name:ILEANA
Middle Name:P
Last Name:MAROON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E H ST
Mailing Address - Street 2:SUITE 1710
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7484
Mailing Address - Country:US
Mailing Address - Phone:619-691-0400
Mailing Address - Fax:619-691-1782
Practice Address - Street 1:374 E H ST
Practice Address - Street 2:SUITE 1710
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7484
Practice Address - Country:US
Practice Address - Phone:619-691-0400
Practice Address - Fax:619-691-1782
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44051122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist